Clinical Documentation Specialist I-CDI
About The Position
The Clinical Documentation Improvement (CDI) Specialist I assists with the appropriate identification of diagnoses, conditions, and/or procedures that are representative of the patient’s hospital stay and care provided, including Severity of Illness (SOI), Risk of Morality (ROM), during an inpatient hospitalization. CDI Specialist I initiates concurrent queries to providers as supported by medical record documentation to improve the accuracy, integrity, and quality of patient data, and drive improvement toward quality physician documentation within the body of the medical record. The CDI Specialist I works under the direction of the Manager of CDI and collaborates with coding, clinicians, medical staff, and physician advisors to improve documentation and the importance of complete and accurate documentation.
Requirements
- Bachelor’s in Nursing, required
- RN License
- 1-2 years of medical/surgical nursing experience in the acute hospital setting.
- Critical Care and/or Emergency Nursing experience required
- Proficient skill in query writing to physicians
- Knowledge to accurately complete chart audits
- Organizational and critical thinking skills required
- Experience with computer systems required, including web-based applications and some Microsoft Office applications which may include Outlook, Word, Excel, PowerPoint, or Access
Responsibilities
- Concurrently reviews inpatient records to ensure completeness, accuracy, and clinical validation.
- Evaluates documentation for assignment of working and possible DRG.
- Recognizes opportunities for documentation improvement, including severity of illness, risk of mortality, core measures, and patient safety/quality.
- Identify opportunities to query physicians regarding missing, unclear, or conflicting documentation.
- Interacts directly with physicians to request and obtain additional documentation when needed.
- Timely follow-up on all unanswered queries based on the query escalation policy.
- Facilitates modifications to physician documentation to reflect the complexity of care of the patient and appropriate reimbursement.
- Maintains a collaborative working relationship with the Health Information Coding staff and serves as a clinical resource.
- Collaborates with and educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing, and case management.
- Performs mortality reviews and optimizes the risk of mortality.
- Maintains review worksheet on all records using CDI software.
- Ensures the accuracy of clinical information used for measuring and reporting physician and hospital quality outcomes.
- Reviews, evaluates, analyzes, and interprets data related to documentation on an ongoing basis.
- Identifies trends or potential problems and assists in developing action plans to address.
- Adheres to ethical and professional business practices.
- All other duties as assigned.
Benefits
- comprehensive compensation and benefits
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
